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hypothermia

Hypothermia

Hypothermia is well recognized to preserve cells and tissue in the face of metabolic challenge. Evidence supports the administration of hypothermia as standard of care for neuroprotection after cardiac arrest from acute coronary syndromes.

There has been long- standing interest in applying hypothermia to reduce the tissue damage associated with central nervous system trauma; however, benefit cannot be presumed. In addition to suggested neuroprotective effects, hypothermia is well known for its ability to reduce intracranial pressure. However, hypothermia bears risks, including coagulopathy and immunosuppression, and profound hypothermia bears the additional risk of cardiac dysrhythmia and death.

see Prophylactic Hypothermia for severe traumatic brain injury

In contrast to previous reviews, a systematic review found some evidence to suggest that therapeutic hypothermia may be of benefit in the treatment of traumatic brain injury. The majority of trials were of low quality, with unclear allocation concealment. Low quality trials may overestimate the effectiveness of hypothermia treatment versus standard care. There remains a need for more, high quality, randomised control trials of therapeutic hypothermia after traumatic brain injury 1).

More robust clinical trials have shown a trend toward worse outcomes with hypothermia or were stopped early because of a low probability of demonstrating superiority 2) 3) 4) 5).

Studies

Pediatric Studies

A literature search for relevant articles in English published from year 2000 up to December 2013 found 19 studies. No signs of improvement in outcome from hypothermia were seen in the five pediatric studies. Varied results were reported in 14 studies on adult patients, 2 of which reported a tendency of higher mortality and worse neurological outcome, 4 reported lower mortality, and 9 reported favorable neurological outcome with hypothermia. The quality of several trials was low. The best-performed randomized studies showed no improvement in outcome by hypothermia-some even indicated worse outcome 6).

Complications

TBI patients may suffer from hypothermia-induced pulmonary and coagulation side effects, from side effects of vasopressors when re-establishing the hypothermia-induced lowered blood pressure, and from a rebound increase in intracranial pressure (ICP) during and after rewarming. The difference between body temperature and temperature set by the biological thermostat may cause stress-induced worsening of the circulation and oxygenation in injured areas of the brain. These mechanisms may counteract neuroprotective effects of therapeutic hypothermia. It is a lack scientific support as a first-tier therapy for the use of therapeutic hypothermia in TBI patients for both adults and children, but it may still be an option as a second-tier therapy for refractory intracranial hypertension 7).

Children suffered TBI may not be able to benefit from therapeutic hypothermia, it may increase risk of fatality and arrhythmia. There is no evidence that therapeutic hypothermia improves prognosis of children with TBI, and no evidence that therapeutic hypothermia raise pneumonia and coagulation dysfunction. Limited by the quality of the included studies, the results need to be treated with caution. Further large-scale, well-designed RCTs on this topic are still needed 8).

1)
Crossley S, Reid J, McLatchie R, Hayton J, Clark C, MacDougall M, Andrews PJ. A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury. Crit Care. 2014 Apr 17;18(2):R75. doi: 10.1186/cc13835. Review. PubMed PMID: 24742169; PubMed Central PMCID: PMC4056614.
2)
Hutchison JS, Ward RE, Lacroix J, et al.. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358(23):2447–2456.
3)
Clifton GL, Valadka A, Zygun D, et al.. Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011;10(2):131–139.
4)
Clifton GL, Miller ER, Choi SC, et al.. Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med. 2001;344(8):556–563.
5)
Maekawa T, Yamashita S, Nagao S, Hayashi N, Ohashi Y; Brain-Hypothermia Study Group. Prolonged mild therapeutic hypothermia versus fever control with tight hemodynamic monitoring and slow rewarming in patients with severe traumatic brain injury: a randomized controlled trial. J Neurotrauma. 2015;32(7):422–429.
6) , 7)
Sandestig A, Romner B, Grände PO. Therapeutic Hypothermia in Children and Adults with Severe Traumatic Brain Injury. Ther Hypothermia Temp Manag. 2014 Mar 1;4(1):10-20. Review. PubMed PMID: 24660099.
8)
Zhang BF, Wang J, Liu ZW, Zhao YL, Li DD, Huang TQ, Gu H, Song JN. Meta-analysis of the efficacy and safety of therapeutic hypothermia in children with acute traumatic brain injury. World Neurosurg. 2014 Dec 13. pii: S1878-8750(14)01381-3. doi: 10.1016/j.wneu.2014.12.010. [Epub ahead of print] Review. PubMed PMID: 25514616.
hypothermia.txt · Last modified: 2017/01/01 15:18 (external edit)